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The Canadian National Breast Screening Study ignites a new round in the mammography wars

The last couple of weeks, I’ve made allusions to the “Bat Signal” (or, as I called it, the “Cancer Signal,” although that’s a horrible name and I need to think of a better one). Basically, when the Bat Cancer Signal goes up (hey, I like that one better, but do bats get cancer?), it means that a study or story has hit the press that demands my attention. It happened again just last week, when stories started hitting the press hot and heavy about a new study of mammography, stories with titles like Vast Study Casts Doubts on Value of Mammograms and Do Mammograms Save Lives? ‘Hardly,’ a New Study Finds, but I had a dilemma. The reason is that the stories about this new study hit the press largely last Tuesday and Wednesday, the study having apparently been released “in the wild” Monday night. People were e-mailing me and Tweeting at me the study and asking if I was going to blog it. Even Harriet Hall wanted to know if I was going to cover it. (And you know we all have a damned hard time denying such a request when Harriet makes it.) Even worse, the PR person at my cancer center was sending out frantic e-mails to breast cancer clinicians because the press had been calling her and wanted expert comment. Yikes!

What to do? What to do? My turn to blog here wasn’t for five more days, and, although I have in the past occasionally jumped my turn and posted on a day not my own, I hate to draw attention from one of our other fine bloggers unless it’s something really critical. Yet, in the blogosphere, stories like this have a short half-life. I could have written something up and posted it on my not-so-secret other blog (NSSOB, for you newbies), but I like to save studies like this to appear either first here or, at worst, concurrently with a crosspost at my NSSOB. (Guess what’s happening today?) So that’s what I ended up doing, and in a way I’m glad I did. The reason is that it gave me time to cogitate and wait for reactions. True, it’s at the risk of the study fading from the public consciousness, as it had already begun to do by Friday, but such is life.
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Posted in: Cancer, Clinical Trials, Public Health

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The Pollyanna Phenomenon and Non-Inferiority: How Our Experience (and Research) Can Lead to Poor Treatment Choices

Pollyanna, a popular children’s book written in 1913 by Eleanor H. Porter, introduced the world to one of the most optimistic fictional characters ever created. She always saw the good in people and her approach to life frequently involved playing “The Glad Game”, where she attempted to find something to appreciate in every situation no matter how unfortunate. She was glad about receiving crutches rather than a doll one Christmas because it was great that she didn’t actually need them. She teaches this philosophy to those around her, even her cantankerous Aunt Polly, and the entire town is transformed into a veritable Mayberry, USA. Later, when she actually does require the use of crutches, her resolve is tested but she triumphantly finds a silver lining.

The Pollyanna principle, first described by Matlin and Stang in 1978 and also known as positivity bias, is a psychological tendency for people to place greater importance on, and assume better accuracy of, descriptive statements about them that are positive. This goes on behind the scenes while our conscious brain tends to dwell on what is perceived as negative stimuli. Though many folks do come across as pessimistic, we are subconsciously biased to accept praise and reject criticism. Anyone who isn’t clinically depressed is on some level more like Pollyanna than Eeyore.

This positivity bias also plays a large role in how we remember past events. As has been covered extensively in prior posts here on SBM, and on Dr. Novella’s excellent Neurologica blog, memory isn’t a replayed video or audio recording of prior events and our interpretations of them, but rather is a reconstruction that is prone to errors during processing and editing that accumulate over time. This leads to false memories that feel no less real than our recollection of what happened five minutes ago.

In this case, the Pollyanna principle results in positive information being more accurately processed and recalled than negative experiences. It also causes our memory of negative events to gradually become less negative as the years go by. I couldn’t have done that terribly during my first high school trumpet solo because I remember people telling me it was pretty good afterwards, right?

So what does this have to do with the practice of medicine? Biases that affect memory also impact how physicians and patients interact. I once assumed the overnight care of a child who had undergone a lumbar puncture performed by one of my female colleagues earlier that day. I ordered no tests and performed no procedures during my brief exposure to the family—yet over a year later when I admitted the same child for a completely different reason I was accused of being the terrible doctor who had unnecessarily subjected their baby to a spinal tap during the last hospitalization. Even after I showed them the documentation which proved that I had nothing to do with that (very appropriate) decision, and that I did not put a needle in their child’s spine, they refused to accept the evidence and had great difficulty trusting my diagnosis and recommendations.
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Posted in: Clinical Trials, Pharmaceuticals

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False “balance” on influenza with an appeal to nature

One of the encouraging shifts I’ve seen in health journalism over the past few years is the growing recognition that antivaccine sentiment is antiscientific at its core, and doesn’t justify false “balance” in the media. There’s no reason to give credibility to the antivaccine argument when their positions are built on a selection of discredited and debunked tropes. This move away from false balance and towards a more accurate reflection of the evidence seems to have started with the decline and disgrace of Andrew Wakefield and his MMR fraud. And there is now no question that antivaccine sentiment has a body count: Simply look at the resurgence of preventable communicable disease. Today, antivaccinationists are increasingly recognized for what they are – threats to public health. It seems less common today (versus just 5 years ago) that strident antivaccine voices are given either air time or credibility in the media.

But false balance on topics like influenza can occur without giving a voice to groups like antivaccinationists. A more subtle technique to shift perceptions is both widespread and hard to detect, unless you’re aware of it: the naturalistic fallacy, known more accurately as the appeal to nature. In short, it means “It’s natural so it’s good” with the converse being “unnatural is bad.” In general, the term “natural” has a positive perception, so calling a product (or a health intervention) “natural” is implying goodness. The appeal to nature is so common that you may not even recognize it as a logical fallacy. Unnatural can be good, and natural can be bad: Eyeglasses are unnatural. And cyanide is natural. Natural doesn’t mean safe or effective. But the appeal to nature is powerful, and it’s even persuasive to governments. If we believe that health interventions and treatments should be evaluated on their merits, rather than whether or not they’re “natural”, then decisions to regulate “natural” products differently than the “unnatural” ones (like drugs) makes little sense. Yet the Dietary Supplement Health and Education Act was a legislative appeal to nature, introducing a different regulatory and safety standard for a group of products while drawing a fallacious distinction with “unnatural” products like drugs. Canada fell for the appeal to nature too: It has the Natural Health Products Regulations which entrenched a lowered bar for efficacy and safety for anything a manufacturer can demonstrate is somehow “natural”. (more…)

Posted in: Science and Medicine, Science and the Media

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HIV Denial and “Just Asking Questions”

The “just asking questions” maneuver is familiar to many skeptics. The idea is to feign neutrality, to insulate oneself from accountability or being held to answer for any specific position, but meanwhile to sow doubt about a scientific claim by raising (dubious) questions.

Sometimes the “I’m just asking questions” gambit also tries to disguise itself as sincere journalism. That’s what journalists do, right, ask the tough questions, uncover the uncomfortable truth?

I find this approach particularly deceptive. It tries to hide the fact that the journalist is working off of a particular narrative. Asking questions is, in fact, just another narrative style, one that is meant to lead the reader/viewer to a particular conclusion about the subject. The narrative determines what questions are asked and how they are answered.

A perfect example of this deceptive approach is the HIV denialist movie, House of Numbers. Here is the synopsis from the movie’s website:

What is HIV? What is AIDS? What is being done to cure it? These questions sent Canadian filmmaker Brent Leung on a worldwide journey, from the highest echelons of the medical research establishment to the slums of South Africa, where death and disease are the order of the day. In this up-to-the-minute documentary, he observes that although AIDS has been front-page news for over 29 years, it is barely understood. Despite the great effort, time, and money spent, no cure is in sight.

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Posted in: General

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How to Think

Robert Todd Carroll, the author of The Skeptic’s Dictionary, has a new book out: The Critical Thinker’s Dictionary: Biases, Fallacies, and Illusion and what you can do about them. Since some of our commenters and most of the CAM advocates we critique are constantly committing logical fallacies, a survey of logical fallacies is a good idea both for us and for them, and this book fits the bill.

When I received the book in the mail, I set it aside, thinking it would be a somewhat boring listing of things I already knew. When I finally got around to reading it, I was surprised and delighted. It held my interest, reminded me of things I had forgotten, explained other things I had never heard of, and provided entertaining stories to illustrate each point. Best of all, the bulk of his examples are taken from medicine and relate directly to the topics we discuss on SBM.

Carroll is well-qualified to write about logical fallacies: he is a retired professor of philosophy who has long promoted skepticism and taught classes in critical thinking, and he writes in an entertaining, accessible style. He started The Skeptic’s Dictionary website in 1994 with 50 articles and it has now grown to several hundred articles. It attracts more than a million visitors a month, and some of its entries have been translated into more than a dozen languages. It has become a go-to reference for anyone seeking the facts on questionable claims about everything from crop circles to homeopathy. Its articles are thorough and well documented with lots of references and links. (more…)

Posted in: Book & movie reviews, Critical Thinking

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The return of the revenge of high dose vitamin C for cancer

Somehow, I’ve a feeling we’re not in Kansas anymore—except that we are, as you will soon see.

Because I’m the resident cancer specialist on this blog, it usually falls on me to discuss the various bits of science, pseudoscience, and quackery that come up around the vast collection of diseases known collectively as “cancer.” I don’t mind, any more than my esteemed colleague Dr. Crislip minds discussing infectious diseases and, of course, vaccines, the most effective tool there is to prevent said infectious diseases. In any case, there are certain things that can happen during a week leading up to my Monday posting slot on SBM that are the equivalent of the Bat Signal. Call them the Cancer Signal, if you will. One of these happened last week, thus displacing that post I’ve been meaning to write on a particular topic once again. At this rate, I might just have to find a way to write an extra bonus post. But not this week.

In any case, this week’s Cancer Signal consisted of a series of articles and news reports with titles like:

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Posted in: Basic Science, Cancer, Clinical Trials

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I Visited a Chickasaw Healer and All I Got Was an Elk Sinew and Buffalo Horn Bracelet

Which headline is real?

  • I Visited a Alchemist. As American alternative chemistry grows in popularity, I decided to experience an even older style of nontraditional transmutation of metals.
  • I Visited an Astrologer. As American alternative astronomy grows in popularity, I decided to experience an even older style of nontraditional stargazing.
  • I Visited a Bloodletter. As American alternative medicine grows in popularity, I decided to experience an even older style of nontraditional treatment.
  • I Visited a Chickasaw Healer. As American alternative medicine grows in popularity, I decided to experience an even older style of nontraditional treatment.

Difficult? They are similar in that alchemy, astrology, bloodletting and (as we will see) Chickasaw healing are not based on reality. Bloodletting, as best I can determine, is not offered in the US, at least based on the notion of an imbalance of the 4 humors. I have no doubts that a reader will find a practitioner, likely with Hepatitis B and C, somewhere in the US. Probably in Sunnydale.

It was the final option, from The Atlantic. Given their medical reporting in the past, I would not be surprised if any of the above headlines originated in that magazine. This gets to an issue I have with all media. There are two things about which I have expertise: infectious diseases and SCAM. So often the media get both wrong, although I probably notice more when they get it wrong in the areas of my expertise. If they get it so wrong in areas about which I know something, how can I trust the veracity of reporting in all the areas where I have no knowledge? (more…)

Posted in: Energy Medicine, Science and the Media

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Twenty days in primary care practice, or “naturopathic residency”

The metastasis of alternative medicine throughout the health care system comes, in no small part, at the hands of the federal and state governments, mostly the latter and most particularly the state legislatures. Under their jurisdiction rests the decision of who can, and cannot, become a licensed health care practitioner, and what they can, and cannot, do. This is the gateway through which much of pseudo-medicine flows.

I’ve read many CAM practitioner licensing statutes (all of the chiropractic practice acts, in fact) and many legislative proposals to license or to expand the scope of practice. Typical of the boilerplate recited in support of this legislation is the education and training of these practitioners, which is touted as a means of protecting the public from charlatans and quacks out there selling snake oil to the credulous. Naturopathic licensing bills routinely require graduation from a naturopathic “medical” school accredited by the Council on Naturopathic Medical Education. (See, for example, Michigan House Bill 4152, which both David Gorski and I have discussed on SBM.) Unfortunately, what CAM provider legislation often does is simply provide legal cover for selling that very same snake oil.

Naturopaths are licensed in 17 states so far, although what they can and can’t do varies considerably. In some states, they have a scope of practice similar to that of an M.D. or D.O. primary care physician. At the most liberal end of this spectrum, N.D.s can prescribe drugs (as Michigan’s bill would allow), although this, too, varies depending on what’s listed on the state’s naturopathic formulary.

All of this has led me to conclude that the state legislatures do not have internet connections. Because, if they did, it would be pretty easy to Google around and figure out just what this naturopathic “medical” education entails and how practicing naturopaths apply their education and training in actual practice. In fact, I’ve done this myself and reported the results here on SBM. In the last day or so, I found out even more by looking around the websites of the Council on Naturopathic Medical Education, the American Association of Accredited Naturopathic Medical Schools, and its member institutions. We’ll get to the fruits of that research in a minute. (more…)

Posted in: Herbs & Supplements, Homeopathy, Legal, Naturopathy, Pharmaceuticals, Politics and Regulation

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Treating Pain Psychologically

One of the goals of rigorous science is to disentangle various causes so we can establish exactly where the lines of cause and effect are. In medicine this allows us to then optimize the real causes (what aspect of treatments actually work) and eliminate anything unnecessary.

Eliminating the unnecessary is more than just about efficiency – every intervention in medicine has a potential risk, so this is also about risk reduction.

It often seems to me that the goal of “alternative” medicine is to blur the lines of cause and effect, to exploit non-specific effects in order to promote a useless but profitable ritual (acupuncture comes to mind).

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Posted in: Clinical Trials, Neuroscience/Mental Health

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Food for Thought

I am excited to tell you about a wonderful new endeavor that is helping to promote critical thinking about science and medicine. It’s a free online course on “Food for Thought” that offers a scientific framework for understanding food and its impact on health and society from past to present.

The “Food for Thought” course is a product of EdX, which offers online college courses from Harvard, MIT, and other prestigious universities. They provide videos with interactive features and access to online student communities. Students can audit a course and get full access to all the materials including tests, assignments, and discussion forums with no commitment, and can choose what and how much they want to do. (more…)

Posted in: Critical Thinking, Nutrition

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